With Dr. Adams in the lead, we entered her room. Leslie did not respond, staring out the window at the prison-like view of brick buildings. The overhead television was tuned to a morning talk show.
“How is your body feeling?” Dr. Adams asked, choosing his words carefully, I suspected, to avoid any discussion about emotional or psychological concerns.
Leslie made eye contact with him for an instant then looked away. “Okay,” she said.
“Are you having any pain?”
“Just a little,” she said.
The two doctors did a brief exam, listening to her heart and lungs, feeling her abdomen, and briefly inspecting her pelvic area for any signs of continued bleeding or infection. Leslie was motionless, only shifting in compliance with the doctors’ requests.
“Is there anything we can get you?” Dr. Adams asked.
She shook her head and continued to look at the television. He told Leslie that she was doing well from a physical standpoint and that someone would come by later to discuss the next steps. Leslie made no acknowledgment that she had even heard him. We then left to discuss her case outside the room.
“I think we should call Psych,” Barbara said. “She may need to be admitted to their unit. I’m worried about suicide, given what’s happened to her and how unresponsive she is.”
“I agree,” Dr. Adams said, as he looked to Dr. Raynor, who would carry out this order. “We’ve done all we can from our end. It’s time for our mental health colleagues to take over.”
After we finished seeing the remaining patients on our unit, I spent the rest of the morning and early afternoon in the hospital prenatal clinic. When I returned to the postpartum unit that afternoon, I met up with Dr. Raynor to get updates on our patients. As we talked, she saw a doctor carrying Leslie’s chart to the physician workroom. It was the psychiatry resident; their team had just finished seeing Leslie. “So what do you think?” Dr. Raynor asked the psychiatrist.
“She’s clearly depressed,” he said. “We talked about her options, and she doesn’t want to go to the state hospital. I don’t think it would help her to force her to go there against her will.”
During my rotation at this facility, the most common cases I saw were paranoid and indefatigable states of psychosis and mania. I tried to visualize Leslie in that setting; it seemed like a bad fit.
“The state hospital,” Dr. Raynor said with a frown. “What about the psych unit here?”
“She doesn’t have health insurance,” the psychiatrist answered. “For those people, the state facility is the only option. Besides, I doubt our unit would have taken her even if she had insurance, given how prominent cocaine is to her presentation.”
It’s a common practice in the mental health world to treat substance abuse as a distinct entity from other mental illnesses, such as severe depression, bipolar disorder, or schizophrenia, although drug use frequently overlaps with these disorders.
“So what about a residential substance abuse program?” Dr. Raynor asked.
“As far as the twenty-eight-day private rehab kind, it’s the same problem of her being uninsured,” the psychiatrist said. “The state-run rehabs require her to get into outpatient counseling before they would authorize her treatment. That’s what we will set her up with.”
“So that’s the best she can get?” Dr. Raynor asked, incredulous.
“Sadly, yes,” he said, his exasperation indicating he felt the same frustration that we did. “The odds are stacked against people like her. We talked about her going to a women’s shelter, as those sometimes can provide the needed structure and support, but she wasn’t too keen on that. I talked with her uncle, who seems like a decent guy. He is willing to take her back, and she’s okay with that. We’ll get her an intake appointment set up. In the meantime, we recommend starting her on Prozac.”
With that, Dr. Raynor began work on Leslie’s discharge papers. It was time for her to leave. Under the current system, the hospital had done all it could for her. As we tied together the final loose ends, I thought back to the heated exchange between Carla and Dr. Garner before we delivered Leslie’s stillborn infant. Much of Carla’s anger, and to a lesser extent Dr. Garner’s and my own, had been targeted at Leslie for selfishly taking a drug that she must have known could be harmful to her growing fetus. But learning her life story had made that judgment a little less fair. The world she grew up in had clearly not been on her side. Perhaps nature had not been either, given her mother’s heroin use and what is known about genetic predispositions to drug abuse.
Still, Leslie had chosen poorly, and her baby had paid the ultimate price. She would have to face the emotional consequences of what had transpired. As far as I could tell, the health care system—where she was easily maligned—wasn’t prepared to provide her much help with that.
Within a few hours, Leslie’s uncle and his wife came to pick her up. They both hugged her fiercely. One could hope that with their support, and with the mental health care we had initiated, this episode might trigger something within Leslie to steer her on a path toward a stable, drug-free life. But with the ashes of this trauma piled atop the many others she had endured in her short life, I wondered where she’d go from here. As a future physician, I was also beginning to think more about the limitations of medicine and where my responsibility to patients might begin and end.
3
Charity Care
“This is it?” I asked.
“That’s it,” Mike said. “It’s a far cry from Duke.”
Sharon simply nodded. We stood beside a cotton field, one hour away from the high-tech hub of Research Triangle Park, which was anchored by Raleigh, Durham, and Chapel Hill. Despite our proximity to the major universities and cosmopolitan residents of these cities, it felt, from my lens as a black northerner, as if we’d been transported back into a black-and-white photograph from the Jim Crow era. A tiny white home, nestled within a group of dingy trailers and makeshift houses, served as the building where we would spend the day treating patients. A small graveled area served as the parking lot. Flowing cotton fields and decrepit buildings filled out the canvas. My mind couldn’t help but conjure up images of Ku Klux Klan rallies a half century earlier.
Although the clinic would not open for twenty minutes, about a half-dozen people stood waiting on the dusty porch. They were all black. While African Americans made up about half the town’s population of two thousand citizens, every person who trekked up the creaky stairway that day was black. This was where the poorest residents came to get care.
Duke’s relationship with the town and clinic dated back nearly fifteen years. For Duke, the project served two purposes: helping patients in an area chronically underserved by doctors, while at the same time giving medical students a practical way to build their clinical skills. For the patients, in a town with no physician and many people without health insurance, the clinic offered some residents their only opportunity to see a doctor. One Saturday each month, these two worlds joined hands.
Earlier that morning, I’d met Mike and Sharon, both third-year medical school classmates, in a parking lot adjacent to Duke Hospital.
“Is there a first-year student coming with us?” I asked Mike.
He shook his head. “It’s just us. They’re all too stressed about their micro test.”
At Duke, third-year medical students formed the backbone of clinic operations. After an intense, compressed beginning to our education—we accomplished in two years what students at other schools did in three—the third year was pretty much ours to do as we wished. Most worked in research labs, as I did, to build our résumés for residency training. Several others went to UNC to earn a master’s in public health, or to Duke’s business school for an MBA.
No matter the choice, life was much less hectic than in those first two pressure-packed years. We worked between forty and fifty hours a week, with weekends and holidays off. We had time for sleep. Time for exercise. Time for travel. It was the closest most of us
would come for many years to living a normal life.
Nonetheless, we were still medical students, and that meant we felt compelled to do at least some extra work to avoid losing a competitive edge. If we went a year without seeing any patients, many of us feared we’d be at a disadvantage when we returned to hospital duties as fourth-years, so we sought out clinical opportunities. It was easy enough to shadow doctors around the hospital, but with many years of specialty-based training ahead of me, I wanted to try something different—away from the high-tech world of what is called tertiary care medicine. The rural clinic, with its opportunity to learn outside Duke and with greater autonomy to build practical medical skills, seemed a perfect fit. Mike, the student leader for the group and future family physician, traveled there most months. Sharon and I were first-timers.
Within a few minutes, two others had joined us: Dr. Watson, a senior medical resident, and Dr. Kelly, a faculty member and supervisor for the day’s activities. The group did not ordinarily include a resident doctor, but Dr. Watson, in the final months of her residency, was preparing to become a supervisor at the clinic. As we clustered around him, Dr. Kelly, a trim, graying endocrinologist, briefly explained our mission. “This is not like anything you’ll see at Duke. Here you are treating people in their own community, without the luxuries we take for granted. Working in a place like this is part of what it means to be a doctor too.”
The clinic was about five hundred square feet, the size of an urban studio apartment or a small single-wide trailer in this part of the world. It had been efficiently divided into three compartments: a makeshift waiting area in the front where a few patients could sit while the rest stood, a central space crowded with medical supplies and a cluttered desk for our supervisors, and two small examination rooms separated by dilapidated curtains.
The first person I saw was Pearl, a woman in her early fifties. She wore a baggy plaid dress that came down to her ankles. Tiny black moles were sprinkled across her forehead. Her eyes lit up as they met mine: “It’s so good to see a young brother in a white coat,” she said. “That don’t happen much ’round here.”
I smiled. In the two-plus years I’d been at Duke, I’d often gotten this reaction from black receptionists, nurses, phlebotomists, cafeteria workers, and cleaning service crew. They shared in my achievements and promise like an extended family. Along with the racial pride that came with their praise and adulation, however, I felt an added weight, as if my success or failure would reflect not just on me, but on those who had come before and those who would follow me.
“Where you from?” she asked. “You look like a boy from the suburbs.”
The implication, as I heard it, was that a black person like me—clean-cut, college-educated, studying to be a doctor—did not come from an area like hers. Nor from the inner city. The odds stacked against those children—bad schools, broken families, negative peer pressure—were, with rare exceptions, too great. While I had grown up in a suburb, it probably wasn’t the kind she had in mind. Mine was the segregated, working-class variety where some of my peers became teenage moms while others got busted for dealing drugs.
I politely answered Pearl’s questions about my background and career interests before turning my attention to her: “So what brings you here today, ma’am?”
“I need my sugar checked,” she said, holding up her calloused hand, pointing to the fingertips where diabetics prick themselves for blood. “I also wanna see if my blood’s high.”
She was referring to screening for diabetes and hypertension. I’d learned these colloquial references from extended family long before discovering the proper medical terminology. My maternal grandmother and her younger sister, both of whom lived in Washington, D.C., often talked about their health problems and those of other family members, gossiping that so-and-so had “high blood” and his wife “had sugar” and how they ultimately “weren’t doing right.” Listening to Pearl was like hearing an old recording after many years.
“Have you been diagnosed with either disease?” I asked her.
“The last time I was checked, they said I was on the borderline for both.”
“When was that?”
“About a year ago. Maybe two,” she admitted. “But I’ve been feeling fine.”
“So what made you decide to come today?” I asked.
“My brother just started dialysis. His doctors said it’s ’cause of his sugar and high blood, so I figured I better get checked out again.”
“Do you take any medications?” I asked.
“I take a water pill once in a blue moon. When I start to feel my legs are swole up. They gave it to me when I came here the last time.”
“Do you know the name of it?”
She shook her head. “It’s a small orange circle.”
That meant nothing to me. I said the names of some common medicines that are described as “water pills,” diuretic drugs that make patients urinate and reduce bodily fluid volume, but Pearl looked at me as if I were speaking Chinese. While we shared the same skin color and lived in the same region, we were communicating in different languages. I knew the textbook names, while she knew what the pills actually looked like.
Unlike other clinics I’d rotated through up to that point, we worked without nurses, so I had to check Pearl’s vital signs. I started off by measuring her height and weight. She was five foot four and weighed 210 pounds, her body mass index far above what my pocket guide listed as ideal. I was more than a foot taller, yet we made the same imprint on the scale. Her blood pressure and blood sugar were both high, measuring 160/100 and 275, respectively. After a physical exam—listening to her heart and lungs with my stethoscope and checking her feet for signs of swelling or poor blood circulation—I found Dr. Kelly, who sat in what amounted to a tiny cubicle.
“So what should we do for her?” he asked me.
“Well, she’s not on medication for either hypertension or diabetes. So I’d probably start her on something for both. But we probably need to get some baseline labs first.”
Dr. Kelly quizzed me on what blood tests to order and seemed pleased with my answers. He appeared less satisfied with my suggestions for medication treatments. I’d thought they were both standard drugs used for these conditions.
“Those drugs might be what we’d prescribe at Duke,” he instructed me.
Out here in this clinic, however, we had other things to think about. For example, we didn’t know whether Pearl had health insurance and prescription drug coverage. And we wouldn’t be able to see her again for at least another month, maybe longer, for follow-up tests.
This kind of concern had never arisen during my two-month family medicine rotation in Durham the previous year. There, in a private-practice setting, the only limitations in choosing a medication for patients were their existing health problems. But here we were practicing a different type of medicine, one constrained by influences beyond basic science.
Dr. Kelly examined Pearl and found signs of nerve damage in her feet. He was also concerned about possible early nerve damage in her eyes. Both were complications of diabetes.
“My Lord,” Pearl said, as she began to fan herself like a woman in a hot southern church. “What’s all that mean for me?”
“The most important part is getting your blood sugar under control,” Dr. Kelly answered. “We’ll need to do some blood tests. You’re also going to need a more specialized eye exam.”
I wondered if the blood tests would show the early stages of kidney disease that had struck her brother, but Pearl’s thoughts had moved away from her health: “I can’t afford all that,” she said. Pearl told us that she had once had health insurance, but lost it five years before when the company she worked for shut down. Her new factory job didn’t offer insurance.
Dr. Kelly looked disappointed but not surprised. “We’ll do the best we can,” he said.
While I drew her blood, Dr. Kelly wrote a prescription for the cheapest diabetic pill available and gave her a
one-month sample pack of blood pressure pills we’d brought along. There was no guarantee that they’d have the same medication samples available the next time, he told her. We handed her a packet of test strips to check her blood sugar, as she told us that she could use her brother’s machine. Finally, we gave her the name of a clinic a half hour away where she could get an eye exam at little or no cost.
“Losing weight will also help out a lot,” Dr. Kelly said. “I know it can be really hard.”
“I need to start walkin’ with my husband every morning. He’s as skinny as I am fat.”
We smiled and wished her well. “Thank you so much,” Pearl said, giving both of us a vigorous two-handed handshake. “I’m gonna make sure I do right with this.”
After she left, I thought about how different this treatment model was from what I’d seen at Duke. Pearl’s medical care seemed so tenuous. As her medical providers, we were nearly ninety minutes away at Duke. And there would be no one here for another month, when a new medical student and physician would pick up where Dr. Kelly and I had left off. What if the weather was unusually bad that day or the medical team got a flat tire on the way to the clinic?
“What if she needs to see a doctor in the meantime?” I asked Dr. Kelly.
“She’ll have to miss work and go to a walk-in clinic,” he said. “Or, if she runs out of options, her nearest emergency room. That’s what happens. She really needs a regular primary care doctor who can manage her diabetes and refer her to the appropriate specialists when needed. But I suppose if she had all of that, she wouldn’t have come to see us in the first place.”
* * *
Physicians and hospitals have been providing what we offered to Pearl and the other people at the rural clinic, charity care, for as long as doctors have been seeing patients. During the first half of the twentieth century, public hospitals became the most well-known American venues for delivering care to the poor; a handful have become famous (New York’s Bellevue, Chicago’s County, and Atlanta’s Grady). Public hospitals began to decline after the mid-1960s passage of Medicare and Medicaid, as these programs provided public insurance that lower-income patients could use for treatment at private hospitals. Combined with other fiscal factors, many public hospitals over the last fifty years have contracted their services or simply closed. But the need for charity care has not declined during this period; if anything, it has grown.
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